Diabetes Mellitus (DM) and Acute Illness or Ketosis without Acidosis Clinical Pathway – ED and Inpatient

Emergency Department and Inpatient Clinical Pathway for Evaluation/Treatment of Children with Diabetes Mellitus (DM) and Acute Illness or Ketosis without Acidosis

Goals and Metrics
Patient Education
Provider Resources
Child with Diabetes and Acute Illness or Ketosis without Acidosis
 
 

Triage

POC glucose, BOHB

Urine Ketones if BOHB unavailable
 
 

Team Assessment

  • Assess
    • MS, VS, hydration
    • Home glucose/ketones, home insulin regimen
  • Initial Labs
    • Review/obtain POC glucose, POC BOHB
    • BOHB ≥ 3 mmol/L, send VBG, BMP to evaluate for DKA
  • History and physical
If acidosis present,
follow DKA pathway

Fluid and Insulin Management

 
 

Diabetic ketosis without acidosis confirmed

POC BOHB ≥ 1 mmol/L
 
 
Initial Insulin Dose
  • ED
    • Weight based: 0.15 unit/kg SubQ rapid-acting insulin only (Aspart)
  • Inpatient
Subsequent Insulin Doses
  • ED and Inpatient
    • Discuss with Endocrine
    • Insulin Dosing Calculations
    • Administer insulin ketone dose or correction bolus, whichever is greater
    • Continue rapid acting insulin administration q2hr until BOHB < 1
Insulin Pump
  • Verify and document recent infusion site change or have family/child change site
  • Continue insulin basal rate
  • Give SubQ rapid-acting insulin q2hr until BOHB < 1
  • Do not use pump for boluses
  • Insulin Pump Management
Hydration
  • Consider ondansetron if nausea, vomiting present
  • PO Hydration Preferred
    • Child to drink 1 oz per age in years every hour, Max 16 oz/hr
      • Blood sugar ≥ 200: Sugar-free fluids
      • Blood sugar < 200: Sugar containing fluids
  • Consider IV NS bolus 20 ml/kg if:
    • Significant dehydration, inability to tolerate PO
    • Add glucose to IVF if blood glucose < 200
Labs Monitoring
  • POC glucose, BOHB q2hr until < 1 mmol/L
Physical Monitoring
  • Monitor I/O hourly
  • VS per nursing standards
 
 
 
 
BOHB < 1
BOHB ≥ 1 after 3–4 doses of insulin
 
 
 
 
  • ED: Discharge
    • Tolerating PO fluids
    • Reassuring VS, physical exam
  • Inpatient or Admission required
    • Resume routine diabetic care
  • ED: Admit to Endocrine
  • Inpatient: Discuss with Endocrine